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San Joaquin Countli 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Erau-Irenrrientaill Health DepartFrm5 lel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILIXT V AND PRACT XT 10MER REGISTRATHOM/ <br /> NIECHAMICAL STUD AND CLASP EAR PIERCING MOTIFICAT CM <br /> I.,pRoCr--DURES'1 a E-H PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> "Branding ®Permanent Cosmetics <br /> 11.RE l9 p RED REGISTRATION,PERMIT,OR NOT IF-KCATIOM FEES:Check all that apply. <br /> Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> Annual Body Art Facility Permit <br /> THIZ.APPLICANT XWORMAT-10 M: <br /> NAME: M, "AA Phone: <br /> Ar, <br /> HOME ADDRESS: 74, Email: <br /> City: qvc, stzt,. <br /> BODY ART PRACTITIONER ONLY <br /> --- <br /> Date oflBirth: Vig Gender: circle one) <br /> identification Type: Drivers License Other Identincation No.: QCf <br /> Facility vAsere Bod[V Art Services Will be Provided <br /> Facility Name:.link-6�-fq 711-finvS Owner: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> WoGdbGrne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:C[locise One and subrnit Documentation <br /> 1[=]Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4 N Vaccination Declination <br /> V.FACILITY LOCAT XOM (S):(Attach additional sheets a necessary) <br /> 1. BUSINESS NAME: :r, n k- ( , M, � -S <br /> Location address: �C>)R C r I V-S 4!1 Suite: <br /> City: <Z41>1 Uc� - - State: CAa Zip: 9��) 2 County: LLA� <br /> V,�4 1 1 <br /> Owner/Contact: vv� Phone/Fax: 72-0!, -(:I->7- -o% <br /> 2. BUSINESS NAME- <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/Fax: <br /> The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local <br /> requirements governin le o art practices or practices governing mechanical stud and clasp ear piercing. <br /> 7 t-ierr--rT,f CeFtlfif L.. movirledge and belief the stat-ementc Made heve?n- are tvue and curvaca. <br /> Signature: Date: —--Lq�,q <br /> Print'Name: Title: <br /> [FIOR OFFICE' USE ONLY <br /> Program (PE): Fees: Authorized by(RENIS): _Date Entered: <br /> T <br />